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German Health Care 2008 – learning from others, or to learn from?

German Health Care 2008 – learning from others, or to learn from?. Reinhard Busse, Prof. Dr. med. MPH FFPH Dept. Health Care Management , Berlin University of Technology (WHO Collaborating Centre for Health Systems Research and Management), Charité – University Medicine Berlin &

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German Health Care 2008 – learning from others, or to learn from?

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  1. German Health Care 2008 – learning from others, or to learn from? Reinhard Busse, Prof. Dr. med. MPH FFPH Dept. Health Care Management, Berlin University of Technology(WHO Collaborating Centre for Health Systems Research and Management), Charité – University Medicine Berlin & European Observatory on Health Systems and Policies

  2. Third-party Payer Population Providers

  3. Collector of resources Third-party payer Regulator Population Providers

  4. “Risk-structure compensation” since 1994/95 Collector of resources Third-party payer Ca. 240 sickness funds Ca. 50 private insurers Wage-related contribution Risk-related premium Strongdelegation& limitedgovernmental control Contracts,mostly collective Choice of fundsince 1996 No contracts Population Providers Choice Social Health Insurance 87%, Private HI 10% Public-private mix,organised in associationsambulatory care/ hospitals The German system at a glance (2007) ...

  5. Proposalsfor healthreform acts Repre-sen-tation Federal Ministryof Health Federal Parliament State Ministriesresponsible for health Federal Assembly(Bundestag) Federal Council(Bundesrat) Delegation = State only defines legal framework Supervision Legislative frame Obligation to secure hospital care Ambulatory Insuree/ Patient Inpatient Enlistment in hospital plans Obligation to treat Obligation to treat Freedom to choose Freedom to choose Physician Obligation to secureambulatory care Hospital 17 (Regional) Physicians’ Associations 16 Regional Hospital Organizations Sectorisation Freedom to choose Obligation to contract Federalism Financial negotiation Federal Association of SHI Physicians Federal Hospital Organization Supervision Financial negotiation Supervision of country-wide funds (via Federal Insurance Authority) Supervision of regional funds Sickness fund Sickness funds in one region “Framework contract” Supervision Supervision 7 Federal associations ofsickness funds Supervision Committee & Institutefor HospitalReimbursment: DRGs Valuation Committee & Institute:Setting of relative point values Supervision Federal Joint Committee (since 2004) Federal Office forQuality Assurance Commissioning Institute for Quality and Efficiency (IQWiG) Statutory health insurance early 2008

  6. Even though certain regulatory institutionsand programmes have become trans-sectoral … Proposalsfor healthreform acts Repre-sen-tation Federal Ministryof Health Federal Parliament State Ministriesresponsible for health Federal Assembly(Bundestag) Federal Council(Bundesrat) Supervision Legislative frame Obligation to secure hospital care Insuree/ Patient Enlistment in hospital plans Obligation to treat Obligation to treat Freedom to choose Freedom to choose Physician Obligation to secureambulatory care Hospital 17 (Regional) Physicians’ Associations 16 Regional Hospital Organizations Freedom to choose Obligation to contract Financial negotiation Federal Association of SHI Physicians Federal Hospital Organization Supervision Financial negotiation Members: 9 sickness funds 9 providers 3 neutral + 9 patients(no voting rights) Supervision of country-wide funds (via Federal Insurance Authority) Supervision of regional funds Sickness fund Sickness funds in one region “Framework contract” Supervision Supervision 7 federal associationsof sickness funds Supervision Committee & Institutefor HospitalReimbursment: DRGs Valuation Committee & Institute:Setting of relative point values Supervision Federal Joint Committee (since 2004) Federal Office forQuality Assurance Commissioning Evaluation ofdrugs etc. Institute for Quality and Efficiency (IQWiG) Joint self-government Statutory health insurance early 2008

  7. … care coordination, quality andcost-effectiveness are problematic • Germany always knew that its health care system was expensive, but was sure it was worth it (“the best system“) • Quality assurance was introduced early but concentrated initially on structure • Increasing doubts since late 1990s: Health Technology Assessment introduced since 1997 • World Health Report 2000: Germanyonly # 25 in terms of performance(efficiency) • International comparative studiesdemonstrate only average quality(especially low for chronically ill)

  8. Legal attempts to improve care coordination/ overcome sectorisation • Pre- and post-inpatient care in hospitals (1997) • „Integrated [i.e. transsectoral] care“ contracts (2000; funded with 1% of expenditure 2004-2008) • Disease Management Programmes (2002) -> next slide • Polyclinics (potentially with hospital owners, 2004) • „GP contracts“ (insured choose GP as gatekeeper; 2004, have to be offered since 2007) • Ambulatory care in hospitals for patients with selected rare/ difficult diseases (2004)

  9. Disease Management Programs(since 2002) • Compensate sickness funds for chronically ill better (make them attractive) = reduce faulty incentives to attract young & healthy • Address quality problems by guidelines/ pathways • Tackle trans-sectoral problems by “integrated“ contracts for diabetes I/ II, asthma/ COPD, CHD, breast cancer • = introduce Disease Management Programsmeeting certain minimum criteria and compensate sickness funds for average expenditure of those enrolling double incentive for sickness funds:potentially lower costs + extra compensation!By end of 2007: 3.8 mn enrolled (5.5% of SHI insured)

  10. DMP diabetes – results(not from official evaluation with post-intervention no control group design) Diabetics not enrolled in DMP Stroke (m) Stroke (f) Foot/ leg Foot/ leg amputations (m) amputations (f)

  11. How does a new technology/ service enter the system? • In ambulatory care officially: Sickness fund or physicians‘ asociation make proposal to Federal Joint Committee which may commission an evaluation through IQWiG; if positive -> passed to Valuation Committee to determine point value • Inofficially moreoften through reformulation of service definition through Valuation Committee • Contrast to inpatient care: Hospital may provide any service which is not explicitly excluded

  12. Federal Office for Quality Assurance (BQS)since 2001 mandatory for almost 1600 hospitals,170 indicators, with feedback and “structured dialogue“ Is the appropriate thing done? Is it done correctly? With what (short-term) results? Indication Process Outcome Inpatient episode

  13. An example (with slow progress): Documentation of operation distance to (breast) cancer

  14. “Risk-structure compensation” since 1994/95 More morbidity orientation?Or less RSC? Collector of resources Third-party payer Ca. 240 sickness funds New payment systems,esp. DRGs in hospitalsDisease Management Programmes,selective contracts (GP models,„integrated care“)Benefit evaluation/ HealthTechnology Assessment Change in funding? „Gesundheitspauschale“,tax funding of children Ca. 50 private insurers Wage-related contribution Risk-related premium Strongdelegation& limitedgovernmental control Contracts,mostly collective Choice of fundsince 1996 No contracts Decision-making:government vs.self-governing actors;patient groups Population Providers Choice Quality assurance:mandatory quality management,annual reports, minimum volumes Social Health Insurance 87%, Private HI 10% Public-private mix,organised in associationsambulatory care/ hospitals Universal coverage?„Bürgerversicherung“ The status before the 2005 election ...

  15. Contributioncollector Third-party payer Providers Population What has or will be changed by the CompetitionStrengthening Act (in force since April 2007)? 1.4.2007: previously SHI insured have right to return1.7.2007: previously PHI insured have right to return 2009: universal coverage PHI remains but: universal coverage +obligation to contract (for a capped premium)

  16. Contributioncollector Third-party payer Providers Population Redesigning the risk-adjusted allocationformula to include supplements for 50 to 80 diseases „Healthfund“ Uniform contributionrate (determinedby government) Hotly debated, especially by richer states(with above average reimbursement level) PHI remains but: universal coverage +obligation to contract (for a capped premium)

  17. „Standardised“ (= avg.) expenditure used for theRisk Structure Compensation mechanism for DMP participants and other insured (2006) Avg. 5.20€/ day

  18. The well-known 20/80 distribution –actually the 5/50 or 10/70 problem How can we predictwho these 5 or 10% are? % of population % of expenditure

  19. 55€ 14% of all insured above legal thresholdfor selected diseases of 1.5x average 16€ 9€ 7,80€ 5,20€ 6€ 3.6€ 2.1€ 1.3€ 50% < 1€

  20. 55€ Current conflict between resigned Expert Council and Ministry,supported mainly by certain large sickness funds, about selection of diseases, especially role of prevalence: “expensive” = expenditure/ person x prevalence? -> should “hypertension” be in? uncomplicated diabetes? … 14% of all insured above legal thresholdfor selected diseases of 1.5x average 16€ 9€ 7,80€ 5,20€ 6€ 3.6€ 2.1€ 1.3€ 50% < 1€

  21. Contributioncollector Third-party payer Providers Population Redesigning the risk-adjusted allocationformula to include supplements for 50 to 80 diseases „Healthfund“ As amount is capped to1% of gross income, sickness funds with poorer members will have problems Belief that insured respond more to a € amount than to a % amout!? Uniform contributionrate (determinedby government) Extra, community-rated premium (positive or negative) No-claim bonuses, individual deductibles … to lower contribution These instruments taken from VHI serve to keep voluntary members inside SHI PHI remains but: universal coverage +obligation to contract (for a capped premium)

  22. Contributioncollector Third-party payer Providers Population Redesigning the risk-adjusted allocationformula to include supplements for 50 to 80 diseases Sickness funds,organized inONE association „Healthfund“ Uniform contributionrate (determinedby government) Extra, community-rated premium (positive or negative) No-claim bonuses, individual deductibles … to lower contribution PHI remains but: universal coverage +obligation to contract (for a capped premium)

  23. Sickness fund reorganisation • One association (under public law) • Previous associations dissolved (may continue on voluntary basis under private law) • Mergers between sickness funds belonging to different associations possible (and happening) • Sickness funds may go bankrupt

  24. Contributioncollector Third-party payer Providers Population Redesigning the risk-adjusted allocationformula to include supplements for 50 to 80 diseases Sickness funds,organized inONE association „Healthfund“ Uniform contributionrate (determinedby government) Still mostly collectivecontracts, but moreselective „integrated care“ contracts New fee schedulefor physicians PHI remains but: universal coverage +obligation to contract (for a capped premium)

  25. Selective contracting for services Allowed within • model projects • „integrated care“ contracts (since 2000/04) • „GP contracts“ (insured choose GP as gate-keeper; may be done without KV since 2007) first contract without KV in Baden- Wuerttemberg (details published today) How to separate capitation payments to KV?

  26. Pharmaceutical policies I Traditional, interventionist approaches • National SHI-wide reference prices • Hard „budgets“ (actually prescription caps) for physicians‘ associations and softer targets for individual practices • Substitution, parallel imports, mandatory rebates for manufacturers • To stimulate price-setting well below RP, patients are exempted from co-payments if price is at least 30% belkow RP (currently ca. 12,000 drugs)

  27. Pharmaceutical policies II Traditional, interventionist approaches • National SHI-wide reference prices • Hard „budgets“ (actually prescription caps) for physicians‘ associations and softer targets for individual practices • Substitution, parallel imports, mandatory rebates for manufacturers • To stimulate price-setting well below RP, patients are exempted from co-payments if price is at least 30% belkow RP (currently ca. 12,000 drugs) New approach since 2007 • Contracts/ public procurement through sickness funds directly with manufacturers • Winning manufacturer gets monopoly for that substance, i.e. no choice for patient, prescribing physician or pharmacist • -> initially ignored by large manufacturers -> turn-over by small Indian/ Israeli ... manufactures increased drastically Current regulatory framework inconclusive (e.g. physicians can hardly be held liable for prescription expenditure as prices under procurement are not known or to be influenced)

  28. Medical aids (medical products on prescription) • Politicians have discovered medical aids as field for regulation relatively recently • -> national reference prices (= max. reimbursement price for sickness funds) per product group since 2005 • -> procurement of medical aids through sickness funds since 2007: contracts with suppliers (not manufacturers!) who get regional monopoly

  29. Fee schedule “Uniform value scale” EBM 2000 plus (since April 2005) • Based on time units • Negotiated value of physicians’ work:0.77 €/ minute (ca. 95,000 €/ year) • Multiplied by estimated average amount to provide service • + monetary value of “technical” component (but devices for individual patients are paid separately through lump sum) • Sum is divided by 0.051 € and expressed in points • Actual reimbursement/ point depends on capitations paid and total number of points, usually around 0.035 €

  30. Sickness fund X Sickness fund Z Sickness fund Y Negotiatedcapitation Physicians‘ association (KV) GP budget(ca. 1/3) Specialists‘budget (ca. 2/3) € dependent on total number of points for delivered services GP 1 GP 2 GP 3 Spec1 Spec2 Spec3

  31. Ambulatory physicians’ fee schedule: changes from 2008/09 • Calculated income of physicians increased from 95,000 € to 105,000 € • Number of points to be increased on average by 10% in 2008 (but with great variations among specialties, favouring GPs) • More services will be included into “quarterly case fees” (especially, but not only for GPs) • Points will be changed to € values in 2009 • Capitation from sickness funds to physicians’ associations will be morbidity-adjusted

  32. Proposalsfor healthreform acts Repre-sen-tation Federal Ministryof Health Federal Parliament State Ministriesresponsible for health Federal Assembly(Bundestag) Federal Council(Bundesrat) Supervision Legislative frame Obligation to secure hospital care Insuree/ Patient Enlistment in hospital plans Obligation to treat Obligation to treat Freedom to choose Freedom to choose Physician Obligation to secureambulatory care Hospital 17 (Regional) Physicians’ Associations 16 Regional Hospital Organizations Freedom to choose Obligation to contract Financial negotiation Members (1.7.08): 5 sickness funds 5 providers 3 neutral + 5 patients(no voting rights)Meetings in public Federal Association of SHI Physicians Federal Hospital Organization Supervision Financial negotiation Supervision of country-wide funds (via Federal Insurance Authority) Supervision of regional funds Sickness fund Sickness funds in one region “Framework contract” Supervision Supervision The federal association ofsickness funds (from 1.7.2008) Supervision Committee & Institutefor HospitalReimbursment: DRGs Valuation Committee & Institute:Setting of relative point values Supervision Federal Joint Committee Federal Office forQuality Assurance Commissioning Evaluation of drugs‘medical cost-benefit etc. Institute for Quality and Efficiency (IQWiG) Statutory health insurance mid 2008

  33. Pharmaceuticals may be subject to economic evaluation by IQWiG: proposed method Eval.Medical Benefit Define Therapeutic Area Select Interventions Identify Consequences Estimate Benefits If superior Benefit on Cardinal scale? Estimate Costs Translate Benefits to Good Horizontal Axis Vertical Axis Plot Efficiency Frontier

  34. Total Cost (/patient) Constructing the frontier (in one therapeutic area) N 7 Existing Therapies 6 Value 5 4 3 2 1

  35. Total Cost (/patient) Decision zones(decision taken by Federal Joint Committee) Superior N 7 Existing Therapies 6 Value 5 4 3 2 1

  36. Conclusions • Competition Strengthening Act has more components than initially relalised • Probably largest structural impact upon system of any reform • In many respects, Germany has learnt from other countries • But: actual implementation will again provide examples for other countries http://mig.tu-berlin.de

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